Citation Nr: 1454943
Decision Date: 12/12/14 Archive Date: 12/17/14
DOCKET NO. 10-48 033 ) DATE
)
)
Received from the
Department of Veterans Affairs Regional Office in Montgomery, Alabama
THE ISSUE
Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD).
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESSES AT HEARING ON APPEAL
Veteran and spouse
ATTORNEY FOR THE BOARD
R. Giannecchini
REMAND
The Veteran had active military service from April 1971 to April 1973.
The present appeal comes before the Board of Veterans' Appeals (Board) on appeal following a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina.
In November 2013, the Veteran and his wife testified before the undersigned Veterans Law Judge (VLJ) during a videoconference hearing.
In a February 2014 decision, the Board denied the Veteran's claims then on appeal for service connection for hearing loss and for tinnitus. It also denied the claim for an initial rating in excess of 30 percent for PTSD. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2014 Order, the Court granted a Joint Motion for Partial Remand (JMPR) of the parties, which requested that the Board's denial of the Veteran's claim for a higher rating for PTSD be vacated and remanded. Later in October 2014, the Board issued the Veteran a letter inviting him to submit additional evidence or argument with respect to his remanded claim. In November 2014, the Veteran's representative submitted a post-remand brief in support of the Veteran's claim.
In the October 2014 JMPR, it was noted that the February 2014 Board decision had failed to adequately account for the Global Assessment of Functioning (GAF) scale finding of 50, as reported by VA mental health clinicians in 2008 and 2009. A GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). According to the DSM-IV, a GAF score ranging from 41-50 is reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social and/or occupational functioning (e.g., no friends, unable to keep a job).
In a report of October 2008 VA examination, the examiner diagnosed the Veteran with PTSD and with a cognitive disorder. The Veteran's PTSD was manifested by mild symptoms. The examiner reported a GAF of 70 for PTSD and a GAF of 50 for a cognitive disorder.
Otherwise, VA outpatient mental health treatment records dated from October 2008 to February 2009 reflect diagnoses for major depressive disorder (MDD), severe, without psychotic features; and a cognitive disorder. A GAF of 50 was reported by clinicians during this period and the Veteran's psychotropic medication was increased. In July 2009, the Veteran was diagnosed with MDD, severe, without psychotic features; and early onset dementia. A GAF of 50 was again reported and the Veteran's psychotropic medication dosage was continued. In October 2009, the Veteran was diagnosed with MDD, moderate, recurrent; and early onset dementia. The Veteran's depression was noted to have improved, his psychotropic medication continued, and a GAF of 50 was reported.
The Veteran was again medically examined for VA purposes in October 2012. The examiner diagnosed the Veteran with PTSD as well as noted that the Veteran's depressive symptoms appeared to be secondary to PTSD and that a separate diagnosis of depression did not appear warranted at that time. The examiner assigned a GAF score of 62.
The Board notes that it could be said that the GAF of 50 reported at various times by VA clinicians is associated with the Veteran's diagnosed cognitive disorder (to include early onset dementia), or related to a psychiatric disorder other than PTSD, that being MDD. With that said, the October 2012 VA examiner commented that besides PTSD, the Veteran had depressive symptoms that appeared secondary to PTSD. The examiner went on to comment that a separate diagnosis of depression did not appear warranted. The VA examiner's comment raises a question about the possibility that symptoms associated with the Veteran's PTSD and the earlier diagnosed MDD are similar. Also, as noted above, VA clinicians identified the MDD as severe.
The Veteran was last examined in October 2012. The most recent VA mental health treatment record associated with the claims folder is dated in January 2013. The clinician at that time noted the Veteran's report of being nervous and that he heard voices. The Veteran's report of hearing voices appears to reflect possible psychotic features.
Therefore, in light of the most recent medical evidence associated with the claims folder, the number of years since the Veteran was last examined for VA purposes, as well as the need for a clinician to interpret the significance of the GAF of 50 as it relates to the Veteran's service-connected PTSD, the Veteran's claim on appeal is remanded for another VA medical examination.
Accordingly, the case is REMANDED for the following action:
1. Associate with the claims folder the Veteran's most recent VA treatment records dated since April 2013.
2. Following completion of the above, schedule the Veteran for a VA examination to evaluate his service-connected PTSD. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. (Advise the Veteran that failure to appear for an examination as requested, and without good cause, could adversely affect his appeal. See 38 C.F.R. § 3.655 (2014).)
The examiner should review the Veteran's VA mental health outpatient treatment records, as well as the reports of October 2008 and October 2012 VA examinations (DBQ). Any testing deemed necessary should be performed. All pertinent psychiatric pathology associated with the Veteran's service-connected PTSD should be noted in the examination report. (The Board recognizes that the Veterans Benefits Administration is now required to apply concepts and principles set forth in DSM-5; however, the Secretary of VA has specifically indicated that DSM-IV is still to be applied by the Board for claims pending before it. 79 Fed. Reg. 45094 (Aug. 4, 2014). Consequently, the examination should comport with DSM-IV.) As part of the evaluation, the examiner is requested to-
a. Comment on the January 23, 2013 VA psychologist outpatient note in which the Veteran reported hearing voices. Is the Veteran's report a sign of psychotic features? If so, what is the etiology of the psychotic features?
b. Assign a Global Assessment of Functioning (GAF) score associated with the Veteran's service-connected PTSD (separate from any other non service-connected psychiatric or cognitive disorder (i.e. early onset dementia)).
c. Comment on the medical probabilities that the GAF of 50 reported by VA clinicians in VA outpatient mental health treatment records dated in October 2008, December 2008, February 2009, July 2009, and October 2009 was consistent with the Veteran's level of impairment associated with his service-connected PTSD as compared to any other non service-connected psychiatric or cognitive disorder (i.e. early onset dementia). Are the symptoms of the Veteran's MDD and PTSD similar/intertwined or indistinguishable?
The examiner must provide the complete rationale for all conclusions reached. If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion and identify precisely what facts could not be determined.
3. After the above has been completed, undertake any additional evidentiary development deemed appropriate. Thereafter, re-adjudicate the issue on appeal. If the benefit sought is denied, the Veteran and his representative must be provided a supplemental statement of the case (SSOC) and be given an opportunity to respond before the case is returned to the Board.
The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).
________________________________
MARK F. HALSEY
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2014).